“Off-label” use of tenecteplase in stroke was increasingly common before the global supply shortage in 2022–2024. Following the recent approval of tenecteplase for stroke by the FDA in the USA, and the expected similar decisions by authorities elsewhere, how do we switch from using alteplase, the default drug for intravenous thrombolysis for the last 20 years, safely and effectively?

The authors outline their method of transitioning a provincial health system of 17 individual stroke centers to the use of tenecteplase in the form of a three-phase time-series analysis. ^{Reference Halabi1} Notably, there were a small number of medication errors in the post-transition period, with only four instances of incorrect dose being administered and with a similar number of patients in the pre-transition period receiving incorrect doses of alteplase. This aligns with previously reported similarity in dosing errors of tenecteplase and alteplase despite the fact that the dosing information supplied with tenecteplase kits included myocardial infarction doses only. ^{Reference Ray, Janzen and Curran2}

An underrecognized issue in the use of alteplase that is not readily captured in the database in assessing dosing errors and in clinical practice everywhere is the time-sensitive nature of infusion commencement following initial bolus dosing. A mere five-minute delay may result in significant decreases in serum concentration ^{Reference Kobayashi, Saito and Kawabata3} – an issue obviated by the use of a “one and done” bolus dose of tenecteplase. Previously reported improvements in door-to-needle time with the use of tenecteplase ^{Reference Ray, Janzen and Curran2} were not seen in this cohort; however, this may speak to previous quality improvement efforts ^{Reference Kamal, Jeerakathil and Stang4} or other factors not recorded.

This paper by Halabi et al. ^{Reference Halabi1} demonstrates the importance of a coordinated and agile approach to deploying system-wide changes to stroke management and provides a model for stroke services in other jurisdictions to enact transitions to new evidence-based treatment.